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<meta name="description" content="第7章 瓷贴面可否用于根管治疗后的牙齿？对于根管治疗后牙齿，设计全冠修复前，总应先考虑瓷贴面修复。7.1 引言瓷贴面适应了牙科界的趋势：减少修复时的牙体预备量。瓷贴面在粘接到牙体组织之前非常脆弱，但粘接以后则有较好的机械抗性。与牙体组织粘接可获得足够的强度，但前提是充分地遵守粘接步骤。7.2 瓷贴面的临床成功需要条件：好的治疗计划、设计良好的牙体预备、技工室精确的贴面制作以及橡皮障隔离下严格依据粘">
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        <p>第7章 瓷贴面可否用于根管治疗后的牙齿？<br>对于根管治疗后牙齿，设计全冠修复前，总应先考虑瓷贴面修复。<br>7.1 引言<br>瓷贴面适应了牙科界的趋势：减少修复时的牙体预备量。<br>瓷贴面在粘接到牙体组织之前非常脆弱，但粘接以后则有较好的机械抗性。与牙体组织粘接可获得足够的强度，但前提是充分地遵守粘接步骤。<br>7.2 瓷贴面的临床成功<br>需要条件：好的治疗计划、设计良好的牙体预备、技工室精确的贴面制作以及橡皮障隔离下严格依据粘接步骤完成粘接。得当的贴面修复似乎更耐久，比全冠更美观。<br>15年观察，临床成功率93%。<br>7.3 微创预备的原则<br>微创牙体预备，未来再干预的可能性较高。<br>采用“引导下预备”技术，保证预备量减少的关键元素包括：加法诊断蜡型模型、硬质精确硅橡胶导板、诊断饰面、以及分段式硅橡胶导板。<br>7.4 确定恰当的上前牙切端位置<br>开始牙体预备前，必须完成诊断蜡型，以帮助与患者沟通，讨论期望的美学效果，预测可能的美学问题。上颌中切牙的最终长度依据休息位上唇的位置和上颌牙齿的关系确定（唇齿分析）。当下颌处于休息位时，牙齿不接触，上下唇轻微分开，上颌切牙切端暴露一部分。暴露量1-4mm，取决于唇的高度、患者的年龄及性别。通常女性及年轻患者休息位时牙齿暴露量较多。发m、e、f/v和s音是对确定一些功能和美学参数非常有价值的帮助。<br>7.5 面弓转移<br>将上颌模型固定到牙合架正确的空间位置上。实现将牙弓三维位置从患者转移至颌架上的工具称为面弓。明确未来的切缘线（与瞳孔连线平行）和中线（与瞳孔连线垂直）是美学治疗设计的基础。面弓帮助在牙体预备时正确地辨别和对齐水平及垂直参考线，因而也能帮助技工室完成修复体的最终制作。<br>7.6 龈上预备或近龈缘预备<br>得益于光线穿透瓷贴面，修复边缘不可见。许多病例无需隐藏边缘，进行龈上牙体预备。有利于橡皮障隔离，简化牙周治疗。牙周治疗时明确贴面边缘位置非常重要，通常来说，应使用手工器械，采用轻柔地探查运动的方式（平行于牙龈缘），且仅在必要时进行（如有残留水门汀或牙结石时）。经过边缘的根冠向器械运动方式应绝对避免。若牙齿变色，预备范围应更大，预备深度更深。牙体预备边缘应为无内线角的浅无角肩台。应终止于釉质，稍位于龈下，到达龈沟中央或近龈缘。建议在牙体预备前进行测量。瓷与牙体组织非常独特和自然的移行，产生“变色龙效应”。<br>7.7 瓷贴面与根管治疗后的牙齿<br>贴面治疗前应尝试进行诊间漂白。若漂白不理想，解决方案之一是增加唇侧牙体预备量，尤其是颈部预备量。但需平衡粘接的需要。牙齿颜色每改变一个色号，至少需要0.2mm牙体预备量。还有更好的选择，通过加法诊断蜡型和诊断饰面预评估，可将牙齿唇侧外形过伸展。<br>另一个限制是牙体组织大面积缺损或大面积复合树脂修复体的情况。缺乏釉质和牙本质的支持，进而带来粘接强度下降，失败风险较高。<br>若无牙齿变色问题，牙体组织缺损范围不大，活髓牙和死髓牙均可采用相同的牙体预备方法。<br>只要可行，瓷贴面修复总应是首选方案。<br>在做出最终决定前，应去除或更换所有有疑问的旧修复体，若牙体组织缺损广泛，应粘接纤维桩。若预备体表面大部分为复合树脂，无法获得足够的釉质或牙本质支持，全冠则是更好的选择。当贴面下为复合树脂时，应喷砂（30μm或50微米氧化铝）以提高粘接水门汀与复合树脂的粘接力。<br>7.8 全瓷系统的选择<br>传统硅基全瓷系统（长石质）最古老，但仍是美学效果最好的瓷贴面全瓷系统。<br>最重要的是选择正确的瓷层，放置于贴面最深部以遮盖变色牙。牙科技师（医生也一样）应理解牙齿荧光性、不透明性和半透明性的本质。<br>为增强遮色效果，可应用白榴石增强型玻璃陶瓷(IPS Empress)，透明度低于长石质玻璃陶瓷，可采用外染或回切技术。<br>二矽酸锂增强型玻璃陶瓷（IPS e.max）是长石质陶瓷的很好替代。强度高，可制作非常薄的贴面，至0.3mm。<br>7.9 治疗步骤<br>①患者评估<br>患者评估：从接诊一直到制作完诊断蜡型，向患者展示。<br>确认：即Mock-up的过程。<br>术前准备：再治疗（如需要）、内\外漂白、粘接纤维桩（如需要）、更换旧树脂修复体。<br>②贴面牙体预备<br>在导板下预备，切端端端相对即可，不用包绕。具体略了。<br>对有牙本质暴露的区域用牙本质粘接剂进行IDS。<br>取模，双线排龈法。<br>面弓转移，咬合记录，取对颌牙列印模。<br>制作临时贴面，可采用点酸蚀粘接技术粘接。<br>③贴面粘接<br>用刮治器去除临时贴面，点状酸蚀的要用刮治器或抛光盘去除粘接树脂。<br>在模型上及口内检查适合性。<br>所有贴面就位，检查邻接触区、颜色。<br>检查美学效果，医生满意后向患者展示，确认。<br>10%HF处理（长石质90s，emax， 5%，20s）<br>水冲洗30s。<br>空气干燥20s（可超声荡洗4-5min）<br>粘接时粘接剂层不应干扰贴面就位；涂布粘接剂时，必须用气流小心将其吹匀，在固化前形成非常薄的一层。<br>硅烷偶联剂处理。<br>应用粘接系统。涂于贴面上的粘接树脂绝不可光固化。<br>避光。<br>试戴完成后局麻，上橡皮障（用B5,B6橡皮障夹）<br>若同时粘接两颗中切牙瓷贴面，两颗贴面应同时就位，避免出现不对称。可使用改良B5橡皮障夹隔离牙齿。<br>用最细的砂(27μm或50μm氧化铝）喷砂，小心清洁预备体表面。<br>仔细用气流吹去预备体表面所有砂粒。<br>橡皮障隔离下试戴贴面（如有阻挡，需调整橡皮障）<br>37%磷酸酸蚀牙面20s，冲洗，吹干（5s）。<br>涂布粘接树脂（至少2层）30s，小心吹薄（10s）<br>光固化（至少20s）<br>按说明书使用粘固树脂水门汀，精确涂布到贴面组织面上，初步就位，指尖小心加压，用探针以切割运动的方式，平行于边缘，初步去除多余树脂。指尖按压需要重复数次，使贴面完全就位（1-5min）。当指尖按压后边缘不再出现新的树脂溢出时，即获得贴面完全备洞就位。初步光固化（5s）以稳定修复体<br>牙线去除邻面多余树脂（从切端移动至牙龈方向，然后从唇侧取出，避免贴面移动。）<br>甘油覆盖所有边缘。光固化。用12#手术刀去除固化后多余树脂，从牙龈缘朝向牙冠部运动。应当在橡皮障下操作。<br>复合树脂抛光杯抛光边缘。<br>在后续贴面粘接前，应检查邻接触点及就位是否顺利。若有阻碍，应在试戴时于贴面和牙齿间放置8μm咬合膜。若咬合膜从邻接区抽出时撕裂，则应使用金刚砂抛光轮小心修整瓷贴面。<br>7.10 瓷贴面与牙齿功能恢复<br>微创牙体预备是瓷贴面临床成功的关键。瓷贴面弹性模量与釉质接近，用于替代釉质已被证明对改善冠部应力分布有效。<br>7.11 结论<br>对于根管治疗后变色牙，正式修复前考虑再治疗和内漂白。当符合间接法修复适应症时，瓷贴面应是优于全瓷冠的治疗方案。制定良好的治疗计划，对使用瓷贴面获得美学及长期成功，十分重要。</p>
<p>总结：正确的治疗设计，微创牙体预备是关键。对贴面患牙进行牙周治疗时，应该确认边缘，不能从根方向冠方越过边缘进行操作。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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